DRS VAN DYK & PARTNERS | VENNOTE
PRACTISE NO: 3803724 REG NO 1995/003519/21 _________________________________________________________________________
DIAGNOSTIC RADIOLOGISTS | DIAGNOSTIESE RADIOLOË
PATIENT DETAILS AND CONTRACT
Surname First name) Relationship To Member Tel. No. (Cell) Dep Language Afr.
Eng.
Initials Date of Birth ID No. (Patient) E-mail address
Title Age
PERSON RESPONSIBLE FOR ACCOUNT
Surname Id No. Member Postal Address Initials Marital Status Physical Add. Title
Postal Code Tel. No. (Home) Tel. No. (Cell) Employer
E-Mail Address Tel. No. (Work) Tel. No. (Fax) Emp. Address
MEDICAL AID
Scheme Name Number Option
FRIEND / RELATIVE INFORMATION
Surname Initials Tel. No. Title Postal Code Address
REFERRING DOCTOR
Name Tel. No.
OTHER INFORMATION
Are you waiting for your images?
Yes
No
If not, when are you seeing your doctor?
If injured, did the injury occur at work?
Yes
No
Date of injury
FEMALE PATIENTS
Is there a possibility that you are pregnant?
Yes No
Date of last Menstrual Period?
METHOD OF PAYMENT
Cash Cheque Credit Card Samba
I, the undersigned, being duly authorised hereto, agree to all the stipulations and conditions herein and in the company's Standard Terms and Conditions, overleaf.
Name Signed Date
Patient Number Barcode Document Type Barcode: Patient Contract
DRS VAN DYK & PARTNERS | VENNOTE
PRACTISE NO: 3803724 REG NO 1995/003519/21 _________________________________________________________________________
DIAGNOSTIC RADIOLOGISTS | DIAGNOSTIESE RADIOLOË
TERMS & CONDITIONS
1. 2. Acceptance
The undersigned acknowledges that he/she shall be liable for the amount charged by Drs Van Dyk & Partners for the examination, inclusive of any required drugs and/or materials used by Drs Van Dyk & Partners.
Terms of Payment
Every payment by the responsible person arising out of or in connection herewith shall be made to Drs Van Dyk & Partners free of deductions and without set off on or before the due date without demand. Drs Van Dyk & Partners will bill the responsible person after the examination or having rendered the service. Payment shall be made immediately in respect of any such bill but not later than 30 days from the date of statement. Drs Van Dyk & Partners will submit the account to your medical aid, but this shall not relieve the responsible person from liability in terms of this agreement. Any payment made by the responsible person or his/her medical aid may be applied by Drs Van Dyk & Partners to such liability of this responsible person to Drs Van Dyk & Partners as they in their sole and absolute discretion may decide. Interest at the margin of 4% per month above the prime bank rates specified by ABSA Ltd. From time to shall be charged by Drs Van Dyk & Partners, at its discretion on any amount not paid by the responsible person on the due date. The amount shall be calculated monthly in advance on the outstanding balance due, on the first date of each calendar month and shall be deducted and capitalised on the same day of each and every month until the total amount due in terms hereof has been paid. NRBPL prices only apply if the patient settles the account immediately on the day of the examination, otherwise our private rates apply. Drs Van Dyk & Partners reserves the right to insist upon settlement of accounts on the day of service. It will, at its sole discretion, decide whether the responsible person will be provided any credit terms.
3.
Breach Should
The responsible person fail to make payment of any amount owing to Drs Van Dyk & Partners on the due date; or The responsible person be provisionally or finally sequestrated or wound-up or liquidated or placed under judicial management or any of his/her assets be attached pursuant to a judgement of any competent Court, or a default judgement be entered against the responsible person in any competent court, the name of the competent person and names of his/her dependants may be put on credit control list for the medical profession.
4.
Notices and Domicilia
The parties respectively choose Domicilia citandi et executandi for the purpose of all notices and processing arising out of or in connection with this agreement as follows: Drs Van Dyk & Partners: Ground Floor, Bloemfontein MEDI-CLINIC Responsible person: At the street address in the face of the payment contract. Any notice sent by either party to the other shall be deemed to be received on the seventh day after posting or on the date of delivery in the case of delivery by hand. Each party shall be entitled to change the address specified by it in terms of the clause to any other address within the Republic of South Africa (not being a post office or poste restante) on not less than 14 days prior written notice to the other party.
5.
General
This agreement constitutes the whole and entire agreement between the parties and there have not been and there are no agreements, representations or warranties between the parties other than those specifically set forth herein; No variation or modification of this agreement shall be of any force or effect unless the same shall be confirmed in writing and signed by the parties. No indulgence on the part of either party in exercising any right conferred upon such party in terms of this agreement shall constitute a waiver or novation of any such right, nor shall any single or partial exercise of any right, preclude any other or future exercise thereof.
6. 7. 8.
Costs
All legal costs, including attorney and client costs, charges and disbursements incurred by Drs Van Dyk & Partners in collecting or endeavouring to collect all or any amount payable by the responsible person hereunder, shall be for the account of the responsible person and be payable on demand.
Certificate of Indebtedness
The certificate of indebtedness of the responsible person to Drs Van Dyk & Partners in terms of the contract shall be determined and conclusively proved for all purposes by a certificate signed by Drs Van Dyk & Partners.
Consent
Drs Van Dyk & Partners is granted permission to disclose any information about the patient, including medical information and/or diagnosis or diagnostic codes, to relevant third parties (such as funders, administrators, switching companies and the like) for purposes of processing payments of accounts in respect of medical services which have been rendered to the patient as required by a specific Act or stature, professional ethics or formal policy or directive applicable to the situation.
I, the undersigned, being duly authorised hereto, agree to all the stipulations and conditions herein.
Name Date
Signed
For Office Use Only
Patient Number Barcode Document Type Barcode: Terms and Conditions